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   2014| July-August  | Volume 18 | Issue 4  
    Online since July 25, 2014

 
 
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REVIEW ARTICLES
The Asia-Pacific Regional Audit-Epidemiology, costs, and burden of osteoporosis in India 2013: A report of International Osteoporosis Foundation
Ambrish Mithal, Beena Bansal, Carey S Kyer, Peter Ebeling
July-August 2014, 18(4):449-454
DOI:10.4103/2230-8210.137485  PMID:25143898
  5,252 1,083 50
BRIEF COMMUNICATIONS
Normative data for stretched penile length in term neonates born in Tamil Nadu
Sudha Rathna Prabhu, Shriraam Mahadevan, R Bharath, Sujatha Jagadeesh, J Kumutha, Seshadri Suresh
July-August 2014, 18(4):585-586
DOI:10.4103/2230-8210.137500  PMID:25143923
Aim: To establish normative data for stretched penile length (SPL) in term male neonates born in Tamil Nadu. Materials and Methods: All live term male neonates delivered in a hospital during a given period were included. SPL was measured from the pubic ramus to the tip of the glans. Two consecutive measurements were taken and average was recorded. Results: The mean SPL observed in our study was 2.83 ± 0.49 cm. Conclusion: This study helps establish normative values for SPL in neonates of Tamil Nadu origin.
  3,429 255 3
LETTERS TO THE EDITOR
Thyroid acropachy: Frequently overlooked finding
Manish Gutch, Saran Sanjay, Syed Mohd Razi, Keshav Kumar Gupta
July-August 2014, 18(4):590-591
DOI:10.4103/2230-8210.137507  PMID:25143927
  3,280 341 2
REVIEW ARTICLES
Diabetes mellitus and suicide
Siddharth Sarkar, Yatan Pal Singh Balhara
July-August 2014, 18(4):468-474
DOI:10.4103/2230-8210.137487  PMID:25143900
Relationship of diabetes mellitus (DM) with metal health disorders such as depression has been explored extensively in the published literatures. However, association of diabetes mellitus with suicidal tendencies has been evaluated less extensively. The present narrative review aimed to assess the literature relating to diabetes mellitus and suicide. As a part of the review, Pubmed and Google Scholar databases were searched for English language peer reviewed published studies with keywords relating to diabetes and suicide. Additional references were identified using cross-references. The available literature suggests that suicidal ideas and attempts are more frequent in patients with diabetes mellitus than healthy or medically ill controls. Although, a few studies report evidence to the contrary. Suicide accounts for a large proportion of deaths in patients with diabetes mellitus type I (T1DM), and their mortality rate is higher than that of age matched control population. Psychological morbidity, including depression, precedes suicidal ideas and attempts; though many other factors can be hypothesized to impact and modulate this association. A common method of suicide attempt in patients with diabetes includes uses of high doses of insulin and its congeners or medications to treat the disease. Regular screening and prompt treatment of depression and suicidality is suggested for patients with DM.
  3,035 561 9
ORIGINAL ARTICLES
Vitamin D levels and microvascular complications in type 2 diabetes
Sarita Bajaj, Raj Pratap Singh, NC Dwivedi, Kamaljeet Singh, Arvind Gupta, Manoj Mathur
July-August 2014, 18(4):537-541
DOI:10.4103/2230-8210.137512  PMID:25143913
Background: Vitamin D has important actions on glucose metabolism. These include improved insulin exocytosis, direct stimulation of insulin receptor, improved uptake of glucose by peripheral tissues, improving insulin resistance. It has got various pleiotropic effects like suppression of cell mediated immunity, regulation of cell proliferation, stimulation of neurotropic factors such as nerve growth factor, Glial cell line-derived neurotrophic factor, neurotropin, suppression of RAAS, reduction of albuminuria, immunomodulatory effects, and anti-inflammatory effects. Thus, vitamin D is implicated in many ways in the pathogenesis of retinopathy, neuropathy and nephropathy. Objectives: To study the correlation of vitamin D levels with microvascular complications in type 2 diabetes. Materials and Methods: Cross-sectional case-control study of 18 patients (18-70 years), who met the American Diabetes Association 2011 criteria for type 2 diabetes, was conducted. Age and sex matched healthy controls were taken. Subjects were evaluated for the presence of microvascular complications by clinical evaluation, urine examination, fundus examination, nerve conduction studies, and various biochemical tests. 25-OH cholecalciferol levels were done for each. Cut off level for vitamin D deficiency was 20 ng/ml. Results: Mean vitamin D was lower in type 2 diabetics than healthy subjects (19.046 vs. 27.186 ng/ml). Prevalence of vitamin D deficiency and insufficiency was found to significantly higher in diabetics when compared to healthy subjects (P = 0.0001). Vitamin D deficiency was found to be significantly associated with neuropathy (χ2 = 5.39, df = 1, P = 0.020), retinopathy, (χ2 = 6.6, df = 1, P = 0.010) and nephropathy (χ2 = 10. 52, df = 1, P = 0.001). Lower levels of vitamin D were found to be associated with increasing prevalence of combinations of microvascular complications namely neuropathy with retinopathy (P = 0.036), neuropathy with nephropathy (P = 0.029), retinopathy with nephropathy (P = 0.022) and neuropathy with retinopathy with nephropathy (P = 0.0001).
  2,240 744 25
A study of bladder dysfunction in women with type 2 diabetes mellitus
Ritu Karoli, Sanjay Bhat, Jalees Fatima, S Priya
July-August 2014, 18(4):552-557
DOI:10.4103/2230-8210.137518  PMID:25143916
Introduction: Diabetes mellitus has been associated with an earlier onset and increased severity of urologic diseases that often result in debilitating urologic complications. Diabetic bladder dysfunction refers to a group of bladder symptoms occurring in patients with diabetes mellitus ranging from bladder over activity to impaired bladder contractility. Aim: Bladder dysfunction is an under evaluated issue in women with diabetes. Aim of our study was to investigate prevalence of bladder dysfunction and its relation with other chronic complications of diabetes in women with type 2 diabetes. Materials and Methods: In a hospital-based cross sectional study, a cohort of women with type 2 diabetes mellitus who had lower urinary tract symptoms (LUTS) were enrolled. We used the American Urological Association Symptom Index (AUA-SI) to assess the severity of LUTS and the Indevus Urgency Severity Scale (IUSS) to assess presence of overactive bladder (OAB). Age-BMI- matched controls that did not have diabetes but had lower urinary tract symptoms were also studied and compared with women with type 2 diabetes. Urodynamic evaluation was done in willing patients. Results: LUTS attributable to bladder dysfunction were reported in 67% of women with type 2 diabetes after exclusion of other causes. Out of them, 36% had moderate to severe LUTS (total AUA-SI score >7). Prevalence of OAB was 53%. Urodynamic evaluation revealed presence of stress urinary incontinence in 48% patients and changes of detrusor over activity and detrusor under activity in 23% and 11% patients, respectively. Among the chronic complications of diabetes, peripheral neuropathy, nephropathy, and presence of metabolic syndrome were significantly associated with moderate to severe LUTS and OAB. Conclusion: Bladder dysfunction is a highly prevalent complication in women with diabetes. Chronic complications of diabetes especially neuropathy, nephropathy, and presence of metabolic syndrome are important predictors of bladder dysfunction.
  2,214 632 18
REVIEW ARTICLES
Medanta insulin protocols in patients undergoing cardiac surgery
Beena Bansal, Ambrish Mithal, Pravin Carvalho, Yatin Mehta, Naresh Trehan
July-August 2014, 18(4):455-467
DOI:10.4103/2230-8210.137486  PMID:25143899
Hyperglycemia is common in patients undergoing cardiac surgery and is associated with poor outcomes. This is a review of the perioperative insulin protocol being used at Medanta, the Medicity, which has a large volume cardiac surgery setup. Preoperatively, patients are usually continued on their preoperative outpatient medications. Intravenous insulin infusion is intiated postoperatively and titrated using a column method with a choice of 7 scales. Insulin dose is calculated as a factor of blood glucose and patient's estimated insulin sensitivity. A comparison of this protocol is presented with other commonly used protocols. Since arterial blood gas analysis is done every 4 hours for first two days after cardiac surgery, automatic data collection from blood gas analyzer to a central database enables collection of glucose data and generating glucometrics. Data auditing has helped in improving performance through protocol modification.
  2,282 541 3
ORIGINAL ARTICLES
Prevalence of iodine deficiency among pregnant and lactating women: Experience in Kolkata
Anirban Majumder, Arvinda Jaiswal, Sudip Chatterjee
July-August 2014, 18(4):486-490
DOI:10.4103/2230-8210.137491  PMID:25143903
Objective: The cross-sectional study was carried out to assess the iodine status of pregnant and lactating mothers, using median urinary iodine excretion (UIE) as the measure of outcome, to document the prevalence of iodine deficiency. Materials and Methods: The present study assessed the UIE in the morning urine samples from 237 pregnant women, 73 lactating mothers and 59 healthy non-pregnant female controls. Results: Out of 237 pregnant women, 88 (37%) exhibited insufficient iodine nutrition (UIE < 150 μg/l), out of 73 lactating mothers, 24 (33%) exhibited insufficient iodine nutrition (UIE < 100 μg/l) and only 3% female control subjects exhibited insufficient iodine nutrition (UIE < 100μg/l). Additionally, a number (32.3%) of babies born of iodine deficient mothers had respiratory distress at birth. Conclusion: It appears that the present salt iodination program is adequate for the general population but insufficient for the pregnant and lactating mothers. They need to be targeted with iodine supplements throughout pregnancy and lactation. Increased incidence of respiratory distress in the new born of iodine deficient mothers merits further study.
  2,087 503 8
LDL-cholesterol: Friedewald calculated versus direct measurement-study from a large Indian laboratory database
Subramanian Kannan, Shriraam Mahadevan, Bharath Ramji, Muthukumaran Jayapaul, V Kumaravel
July-August 2014, 18(4):502-504
DOI:10.4103/2230-8210.137496  PMID:25143906
Background: Validity of Friedewald formula (FF) in patients with serum triglycerides (TGs) <400 mg/dl is unclear. Materials and Methods: We compared low-density lipoprotein (LDL)-cholesterol calculated by FF to directly measured LDL in a laboratory database of 14,620 lipid profile samples from south India. Results: LDL by FF correlated with directly measured LDL with correlation coefficient of 0.89 with the best correlation seen in TG levels 100-150. Higher level of TG (>200) underestimates the LDL calculated by FF particularly at LDL values <70 mg/dl. On the other hand, LDL is overestimated by FF in more than 70% of cases at LDL levels >130 mg/dl. Conclusion: We suggest repeating the LDL by direct assay techniques particularly in patients with TG >200 and when LDL <70 or >130. This helps in correctly stratifying the coronary artery diseases' (CADs') risk and goals of treatment.
  2,151 420 10
Metabolic syndrome: Performance of five different diagnostic criterias
S Ogedengbe Onesi, U Ezeani Ignatius
July-August 2014, 18(4):496-501
DOI:10.4103/2230-8210.137494  PMID:25143905
Background: The aim of this study is to describe the metabolic syndrome (MS) and to evaluate five diagnostic criteria of the MS with respect to their sensitivity and specificity in patients with type 2 diabetes mellitus (T2DM). Materials and Methods: It is a cross-sectional case control study of T2DM patients and their first degree relatives (FDRs) recruited using convenience sampling and data collected through questionnaire administered technique. Variables of interest included anthropometric indices, blood pressure, serum lipid profile, fasting blood sugar (FBS), proteinuria, and microalbuminuria. The Chi-square test was used for comparison of proportions. A P value of less than 0.05 was taken as statistically significant. Kappa statistic was used to test the degree of agreement between the diagnostic criteria. Results: The World Health Organization (WHO), International Diabetes Federation (IDF), revised National Cholesterol Education Program (NCEP-R), NCEP Adult Treatment Panel (ATP)-III, and American Association of Clinical Endocrinologists (AACE) criteria reported a prevalence of 87.1, 64.5, 61.3, 55.6, and 22.6%, respectively in persons with T2DM. Using the WHO criteria as a reference or gold standard, the sensitivity of the IDF, NCEP-R, NCEP ATP-III, and AACE criteria among persons with T2DM were 71.3, 67.6, 61.1, and 25.9% respectively. Using the WHO criteria as a reference or gold standard, the specificity of the IDF, NCEP-R, NCEP ATP-III, and AACE criteria among persons with T2DM were 81.3, 81.3, 81.3, and 100%, respectively. Using the WHO criteria as a reference or gold standard, the level of agreement of the IDF, NCEP-R, NCEP ATP-III, and AACE criteria with the WHO criteria among persons with T2DM (as estimated by the kappa statistics) were 0.30, 0.26, 0.21, and 0.08 respectively. Conclusion: The level of agreement appears to be generally poor, though the IDF criteria showed a fair level of agreement with the WHO criteria: Therefore the IDF criteria is recommended for screening of the MS in persons with T2DM because of its ease of application and its level of agreement with the WHO criteria being the best compared to the other three criteria.
  1,773 511 3
Efficacy of insulin lispro in improving glycemic control in gestational diabetes
MC Deepaklal, Kurian Joseph, Rekha Kurian, Nandita A Thakkar
July-August 2014, 18(4):491-495
DOI:10.4103/2230-8210.137492  PMID:25143904
Aim: To assess the safety and efficacy of insulin lispro in improving glycemic control in patients with gestational diabetes. Materials and Methods: A retrospective observational study was conducted at a single center on 201 gestational women with diabetes. Subjects who received insulin lispro performed blood glucose self-monitoring and recorded the readings in the fasting state and 1 h after each meal. At each contact (in person or telephonic contact), the insulin dose was adjusted based on the readings measured. A total of 53 subjects also recorded glucose levels post-partum. Pregnancy and post-delivery glucose level and insulin requirements of these 53 patients were compared. Results: Analysis of glucose levels both fasting and post-prandial glucose levels revealed that after using insulin lispro, the number of episodes of post-prandial hyperglycemia (1 h plasma glucose >120 mg/dL) was minimal and so was the incidence of hypoglycemia. Hypoglycemia was defined as a blood sugar value of. There was neither any congenital abnormality except for a poorly formed pinna in the right ear of one baby nor any post-partum complications of note. Conclusion: Insulin lispro is an effective and safe treatment option in gestational diabetes.
  1,518 410 1
Effects of the anti-receptor activator of nuclear factor kappa B ligand denusomab on beta thalassemia major-induced osteoporosis
Mohamed A Yassin, Ashraf T Soliman, Vincenzo De Sanctis, Mohamed Osman Abdelrahman, Elsaid M Aziz Bedair, Manal AbdelGawad
July-August 2014, 18(4):546-551
DOI:10.4103/2230-8210.137516  PMID:25143915
Introduction: Osteoporosis represents the second most common cause of endocrinopathy in patients with beta thalassemia major (BTM). Some drugs proved effective to reduce vertebral and non-vertebral fracture risk. Denosumab is a fully human monoclonal antibody to the receptor activator of nuclear factor kappa B ligand (RANKL), a member of the tumor necrosis factor receptor superfamily essential for osteoclastogenesis. The efficacy and safety of denosumab in BTM-induced osteoporosis has not been tested. Objective: To evaluate the efficacy and safety of anti-RANKL on the biochemical and radiological parameters of bone mineralization in patients with BTM-induced osteoporosis. Design: The study population was selected using the random sampling method from the patient's database of our thalassemia clinic. Transfusion-dependent BTM patients above 18 years with no history of treatment with bisphosphonates were randomly selected. Bone mineral density (BMD) of the lumbar spine (LS) and right femoral neck (FN) were measured by dual energy X-ray absorption (DEXA) scan using a calibrated method. Independent factors likely to be associated with low bone mass were determined and included in the analysis to ascertain possible associations. Patients and Methods: We studied 30 patients with BTM-induced osteoporosis as per World Health Organization criteria (T Score of less than − 1.0 being defined as osteopenic and a T Score of less than − 2.5 being referred as osteoporotic). 19 males and 11 females aged between 18 and 32 years, with full pubertal development (Tanner's stage 5) at the time of the study. Their mean serum ferritin concentration was 3557 ng ± 1488 ng/ml. Every patient underwent DEXA scan as a baseline and after 12 months of denosumab therapy. Biochemical evaluation including serum concentrations of creatinine, Na, K, calcium, phosphorus, parathormone, bone specific alkaline phosphatase and type 1 collagen carboxy telopetide (ICCT) using enzyme-linked immunosorbent assay (Nordic Bioscience Diagnostics A/S) was done at baseline, after a month and then every 3 months for 12 months after starting denosumab. 60 mg of denosumab was administered subcutaneously twice yearly for a year. The mean BMD T Scores at baseline were −2.7 at the LS and −2.1 at the FN. Results: Denosumab therapy for a year was associated with a significant increase in BMD of 9.2% (95% confidence interval [CI], 8.2-10.1) at the LS and 6.0% (95% CI, 5.2-6.7) at the FN. Denosumab treatment decreased serum ICCT levels by 56% at 1 month and normalized them in all patients at 1 year. Significant correlations were found between BMD T Score before and 1 year after denosumab in LS (r = 0.752, P < 0.001) and FN (r = 0.758 P < 0.001), respectively. The most common side effects were pain in the back and extremities (12%) and nausea (10%). Asymptomatic hypocalcaemia occurred in two patients. Conclusion: Denosumab therapy for a year significantly increased BMD density at LS and FN of patients with BTM and was associated with a rapid and sustained reduction in ICCT levels. Further studies are required to confirm long-term effects of this therapy.
  1,415 459 11
EDITORIALS
Classification of hyperglycemia in pregnancy
Veeraswamy Seshiah, Sanjay Kalra, Sanjay Gupte, Hema Divakar, A Murugananthan, Samar Banerjee, Sunil Gupta, Vijayam Balaji, AH Zargar, AK Das, Rakesh Sahay, Jitendra Singh, Shaukat Sadikot, Rajesh Khadgawat
July-August 2014, 18(4):445-448
DOI:10.4103/2230-8210.137484  PMID:25143897
  1,424 402 -
ORIGINAL ARTICLES
Switching from basal or basal-bolus insulin to biphasic insulin aspart 30: Results from the Indian cohort of the A 1 chieve study
Arpandev Bhattacharyya, Raman Shetty, C Rajkumar, Ganapathi Bantwal
July-August 2014, 18(4):480-485
DOI:10.4103/2230-8210.137490  PMID:25143902
Aim: To determine the safety and efficacy of biphasic insulin aspart 30 (BIAsp 30) therapy in the Indian patients with type 2 diabetes previously on basal or basal-bolus insulin therapies. Materials and Methods: Patients switching from insulin glargine, neutral protamine Hagedorn (NPH) insulin, or basal-bolus insulin to BIAsp 30 in the Indian cohort of the A 1 chieve study were included. Safety and efficacy of treatment was evaluated over 24 weeks. Results: A total of 422 patients (pre-study basal-bolus insulin, 49; NPH insulin, 157; insulin glargine, 216) switched to BIAsp 30. Pre-study insulin doses were 0.61 ± 0.26 U/kg, 0.34 ± 0.2 U/kg and 0.40 ± 0.21 U/kg and the mean week 24 BIAsp 30 doses were 0.50 ± 0.21 U/kg, 0.35 ± 0.15 U/kg and 0.42 ± 0.16 U/kg in the prior basal-bolus insulin, NPH insulin and insulin glargine groups, respectively. No serious adverse drug reactions, major or nocturnal hypoglycemia were reported. The proportion of patients experiencing overall hypoglycemia was significantly lower from baseline (5.6%) to week 24 (1.0%) in the pre-study insulin-glargine group and appeared to be lower in pre-study NPH insulin and basal-bolus insulin groups. Glycemic control improved significantly from baseline week 24 in the pre-study NPH insulin and insulin-glargine groups (P < 0.001), while it appeared to improve in the pre-study basal-bolus group. Quality of life was positively impacted after 24 weeks in all 3 groups. Conclusion: The switch from basal or basal-bolus insulin to BIAsp 30 was safe, well tolerated and improved the glycemic control in this Indian cohort.
  1,499 324 -
BRIEF COMMUNICATIONS
Completion report : Effect of Comprehensive Yogic Breathing program on type 2 diabetes: A randomized control trial
VP Jyotsna, Anju Dhawan, V Sreenivas, KK Deepak, Rajiv Singla
July-August 2014, 18(4):582-584
DOI:10.4103/2230-8210.137499  PMID:25143922
Background: Yoga has been shown to be benefi cial in diabetes in many studies, though randomized control trials are few. The aim of this randomized control trial was to see the effect of Sudarshan Kriya and related practices (comprehensive yogic breathing program) on quality of life, glycemic control, and cardiac autonomic functions in diabetes. Diabetes mellitus is a risk factor for sudden cardiac death. Cardiac autonomic neuropathy has been implicated in the causation of sudden cardiac death. Therefore, a maneuver to prevent progression of cardiac autonomic neuropathy holds signifi cance. Materials and Methods: A total of 120 patients of diabetes on oral medication and diet and exercise advice were randomized into two groups: (1) Continued to receive standard treatment for diabetes. (2) Patients administered comprehensive yogic breathing program and monitored to regularly practice yoga in addition to standard treatment of diabetes. At 6 months, quality of life and postprandial plasma glucose signifi cantly improved in the group practicing yoga compared to baseline, but there was no significant improvement in the fasting plasma glucose and glycated hemoglobin. Results: On per protocol analysis, sympathetic cardiac autonomic functions signifi cantly improved from baseline in the group practicing comprehensive yogic breathing. Conclusion: This randomized control trial points towards the beneficial effect of yogic breathing program in preventing progression of cardiac neuropathy. This has important implications as cardiac autonomic neuropathy has been considered as one of the factors for sudden cardiac deaths.Keywords: comprehensive yogic breathing program, diabetes mellitus, cardiac autonomic function
  1,345 388 9
ORIGINAL ARTICLES
Immunoregulatory T cells, LFA-3 and HLA-DR in autoimmune thyroid diseases
Aml Mohamed Nada, Maha Hammouda
July-August 2014, 18(4):574-581
DOI:10.4103/2230-8210.137524  PMID:25143920
Several reports have claimed a role for T regulatory cells (Tregs) in the pathogenesis of various autoimmune diseases, including autoimmune thyroid diseases (AITD). Naturally occurring CD4+ regulatory T cells, the majority of which express CD25, are engaged in dominant control of self-reactive T cells, contributing to the maintenance of immunologic self-tolerance. Their depletion or functional alteration leads to the development of autoimmune diseases. CD8+ Tcells are also claimed to have a suppressive effect on autoimmune diseases. Lymphocyte function antigen-3 and human leucocyte antigen (HLA-DR) are involved in antigen presentation, initiation, and maintenance of autoimmune processes. Aim: The aim of the present study was to examine the changes in the expression of T-cell activation markers, namely CD4+ CD25+ and CD8+ in patients with AITD, namely Graves' disease and Hashimoto's thyroiditis as well as colloid nodular goitre. HLA-DR, LFA-3, and peripheral total lymphocytic count are also measured. Materials and Methods: We compared the expression of CD4, CD25, and CD8 surface markers in peripheral blood lymphocyte in Graves' disease and Hashimoto's thyroiditis as autoimmune thyroid diseases, as well as colloid goitre in comparison with healthy controls. Also, LFA-3 and HLA-DR were measured in the same groups using three-color flow cytometry. Total lymphocytic count in peripheral blood, thyroid function tests, antithyroid antibodies were also included in the laboratory investigations. The total number of participants was 65. All were recruited from endocrine clinics in a tertiary care hospital in the southern region of Saudi Arabia. All participants underwent history taking, clinical examination, laboratory workup, and radiological investigations. Neck ultrasound, technecium pertechnetateψψ thyroid uptake, and fine-needle aspiration and cytology (FNAC) of the thyroid were done when indicated. The study was approved by the Hospital Research Isthics Committee and informed consents were obtained from all participants before enrollment in the study. Results: In comparison with thecontrol group, activation markers CD4, CD25, and CD8 were lower in the autoimmune thyroid diseases. Lymphocyte function antigen-3 (CD58) and total lymphocytic count were higher in the AIT diseases whereas HLA-DR was lower than that in the control group. The CD4/CD8 ratio was lower in the AITD compared with the healthy euthyroid subjects. No difference was found between patients with colloid nodular goitre and the healthy control in any of the study variables except for LFA-3 which was significantly higher in the colloid goitre group. Conclusion: Our findings indicate downregulation of CD4+ CD25+ Treg as well as CD8+ T cells in autoimmune thyroid diseases. Downregulation of suppressor T lymphocytes helps initiation, progression, and maintenance of the autoimmune thyroid diseases. Lower HLA-DR and higher CD58 in AITDs indicate their role in the expression of the autoantigen and its escape from the immune surveillance. High levels of LFA-3 in colloid goitre indicate that the autoimmune process needs interacting factors, and not only the high level of LFA-3.
  1,362 332 11
Differential response of idiopathic sporadic tumoral calcinosis to bisphosphonates
Karthik Balachandran, Sadishkumar Kamalanathan, Jaya Prakash Sahoo, Ashok Kumar Das, Dhanapathi Halanaik
July-August 2014, 18(4):521-525
DOI:10.4103/2230-8210.137511  PMID:25143910
Context: Tumoral calcinosis is a disorder of phosphate metabolism characterized by ectopic calcification around major joints. Surgery is the current treatment of choice, but a suboptimal choice in recurrent and multicentric lesions. Aims: To evaluate the efficacy of bisphosphonates for the management of tumoral calcinosis on optimized medical treatment. Settings and Design: The study was done in the endocrine department of a tertiary care hospital in South India. We prospectively studied two patients with recurrent tumoral calcinosis who had failed therapy with phosphate lowering measures. Materials and Methods: After informed consent, we treated both patients with standard age adjusted doses of bisphosphonates for 18 months. The response was assessed by X ray and whole body 99mTc-methylene diphosphonate bone scan at the beginning of therapy and at the end of 1 year. We also estimated serum phosphate levels and urinary phosphate to document serial changes. Results: Two patients (aged 19 and 5 years) with recurrent idiopathic hyperphosphatemic tumoral calcinosis, following surgery were studied. Both patients had failed therapy with conventional medical management − low phosphate diet and phosphate binders. They had restriction of joint mobility. Both were given standard doses of oral alendronate and parenteral pamidronate respectively for more than a year, along with phosphate lowering measures. At the end of 1 year, one of the patients had more than 95% and 90% reduction in the size of the lesions in right and left shoulder joints respectively with total improvement in range of motion. In contrast, the other patient (5-year-old) had shown no improvement, despite continuing to maintain normophosphatemia following treatment. Conclusions: Bisphosphonate therapy in tumoral calcinosis is associated with lesion resolution and may be used as a viable alternative to surgery, especially in cases with multicentric recurrence or treatment failure to other drugs.
  1,406 261 1
Vitamin D deficiency is associated with increased mortality in critically ill patients especially in those requiring ventilatory support
Ameya Joshi, Rakesh Bhadade, Premlata K Varthakavi, Rosmarie DeSouza, Nikhil M Bhagwat, Manoj D Chadha
July-August 2014, 18(4):511-515
DOI:10.4103/2230-8210.137504  PMID:25143908
Introduction: Vitamin D (VitD) classically recognized for its role in the musculoskeletal system, has been implicated in myriad of conditions such as diabetes, immune dysfunction, cancers, heart disease, metabolic syndrome, etc. We studied the role of VitD in acute care setting and its correlation with mortality. Materials and Methods: A total of 85 consecutive consenting patients admitted in medical intensive care unit of tertiary care hospital who fulfilled the inclusion criteria were included. All patients were evaluated clinically, and blood samples were collected for hemogram, biochemical investigations including serum calcium, phosphorus, alkaline phosphatase, magnesium, along with 25(OH) VitD, 1,25(OH) VitD and intact parathormone levels. Simplified acute physiology score (SAPS II) was calculated for all patients. Results: VitD was deficient (<30 ng/ml) in 27 patients (32%). The overall mortality was more in VitD deficient group as compared to VitD sufficient group (74 vs. 41%; P < 0.05). The actual mortality in VitD deficient group was higher than the mortality predicted by SAPS II score (50 vs. 74%; P < 0.0507). VitD deficiency was also associated with more mortality among those requiring ventilator support (95% vs. 40%; P < 0.05) as well as with higher blood glucose (124.5 ± 29.7 vs. 94.8 ± 19.8: P < 0.01) levels. Conclusion: VitD deficiency was associated with increased mortality, poor ventilator outcomes, and increased blood glucose in critically ill patients.
  1,147 509 1
Undiagnosed diabetes mellitus in tuberculosis: A Lagos report
Anthonia Okeoghene Ogbera, Anil Kapur, Sunday Chinenye, Olufemi Fasanmade, Andrew Uloko, Kofo Odeyemi
July-August 2014, 18(4):475-479
DOI:10.4103/2230-8210.137488  PMID:25143901
Background: Tuberculosis (TB) and diabetes mellitus (DM) are two diseases that are individually relatively common and of immense public health significance globally. There is a growing awareness on a global scale on the possible relationship between TB and DM. Nigeria is a country with a high burden of TB and an increasing incidence of DM. We set out to determine the frequency of occurrence of undiagnosed DM in TB patients. Materials and Methods: This was an observational study that was carried out in TB patients recruited from 56 DOT centers in Lagos, Nigeria. The main objective of the study was to determine the disease burden of DM in patients with TB by comparing the frequency of occurrence of DM in TB to the occurrence of DM in people without TB. Screening was carried out by staff-nurses and community health workers-of these DOT facilities who all had capacity building on the detection of DM at the start of the project. Results: Of 4000 TB patients, a total of 480 (12.3%) had DM. Of the pool of DM patients, newly diagnosed cases of DM were 310 (8%) in number and previously known persons with DM were 170 (4.3%). The newly diagnosed cases of DM made up 64% of the cases of DM. In the study population without TB, a total of 112 (5.6%) had DM. The number of newly diagnosed cases of DM were 40 in number and these made up 2% of this study group. The number of persons who were already known to have DM was 72 and these made up 3.6% of the study population. New cases of DM made up 44% of the total number of cases of DM detected in persons without TB. Conclusion: The detection rates of DM in patients with TB are higher than in persons without TB. Given the fact that DM may negatively impact TB treatment, we suggest that routine screening be carried out for TB in persons with DM.
  1,243 398 7
Association between adolescence obesity and metabolic syndrome: Evidence from Isfahan Healthy Heart Program
Alireza Ahmadi, Mojgan Gharipour, Fatemeh Nouri, Roya Kelishadi, Masoumeh Sadeghi, Nizal Sarrafzadegan
July-August 2014, 18(4):569-573
DOI:10.4103/2230-8210.137523  PMID:25143919
Background: Metabolic syndrome (MetS) is more prevalent among Iranian adolescences. This study aimed to find the relationship between obesity and MetS among different education grades of Iranian adolescence. Materials and Methods: Overall, 1039 junior high school and 953 high school students were selected using multistage random sampling. Fasting blood sugar, total cholesterol, triglyceride (TG), and high-density lipoprotein cholesterol (HDL) were measured. Trained individuals measured waist circumference and blood pressure. MetS was defined according to the De Ferranti definition. Results: The prevalence of overweight and obesity was 12.6% and 6.2% in junior and 11.5% and 4.3% in high school students, respectively. Obese subjects in both grades have higher waist circumference, systolic and diastolic blood pressure, and triglyceride than comparable groups. Multiple logistic regression models showed that overweight and obesity were strongly associated with MetS components analyzed. Compared to normal-weight children, overweight and obese in junior high school students were 1.47 and 2.23 times more likely to be having high TG, respectively, whereas overweight and obese in high school-students were also more likely to have elevated TG [ORs 1.94 (1.28-2.94), 4.96 (2.39-10.3) respectively]. Conclusion: Obese children have the highest prevalence of MetS. Prevalence of MetS-related components has reached high level among Iranian adolescences that were overweight or obese.
  1,244 366 2
Serum monocyte chemoattractant protein-1 is a biomarker in patients with diabetes and periodontitis
Preethi Radhakrishnan, Padma Srikanth, Krishna G Seshadri, Ramya Barani, Maitreya Samanta
July-August 2014, 18(4):505-510
DOI:10.4103/2230-8210.137498  PMID:25143907
Introduction: The role of serum Monocyte Chemoattractant Protein-1 (MCP-1) as a biomarker of periodontitis is well documented; however, its role in diabetic patients with periodontitis is unknown. Aim : This study was conducted to determine the presence and concentration of serum MCP-1 in diabetic patients with and without periodontitis and correlate it glycemic status with periodontitis. Materials and Methods: Adult diabetic patients were enrolled and grouped into group I, II, and III based on their glycemic status and serum MCP-1 estimated by ELISA. Linear regression and correlation tests were performed using R statistical software, Medcalc software to observe correlation between the serum MCP-1 and glycated hemoglobin level among different groups. Results: Serum samples obtained from 37 patients tested positive for MCP-1. Mean serum MCP-1 concentration was highest (482.3 pg/ml) in group III, lowest (149.3 pg/ml) in group I, and intermediate 398.8 pg/ml in group II. Correlation and regression analysis was done between HbA1c and serum MCP-1. A significant positive correlation (P < 0.001) was observed. Serum MCP-1 increased by 37.278 pg/ml for every 1% rise in HbA1c, and the levels were raised in group II and group III than in group I irrespective of their glycemic status. With an HbA1c range of 6.5-6.9% (group II), the serum MCP-1 values cluster around 380-410 pg/ml. Elevated levels of serum MCP-1 (>500 pg/ml) in three subjects corresponded to HbA1c values more than 12.2% (group III). Conclusion: To our knowledge, this is the first study to document serum MCP-1 levels in diabetic patients with periodontitis. Glycemic status influences serum MCP-1, and lack of glycemic control contributes to increased serum MCP-1 levels. Serum MCP-1 may thus serve as a biomarker of inflammation and disease progression in diabetes with periodontitis.
  1,278 320 2
EDITORIALS
Osteoporosis treatment in India: Call for action
Premlata K Varthakavi, Ameya S Joshi, Nikhil M Bhagwat, Manoj D Chadha
July-August 2014, 18(4):441-442
DOI:10.4103/2230-8210.137482  PMID:25143895
  1,252 325 5
LETTERS TO THE EDITOR
Interventional endocrinology: A futuristic Perspective
Amado Jiménez Ruiz
July-August 2014, 18(4):591-591
DOI:10.4103/2230-8210.137509  PMID:25143928
  1,415 150 -
ORIGINAL ARTICLES
Hormonal profile in children with isolated hypospadias associates better with comprehensive score of local anatomical factors as compared to meatal location or degree of chordee
Simmi K Ratan, Satish K Aggarwal, Tarun Kumar Mishra, Alpna Saxena, Sangeeta Yadav, Ravindra M Pandey, Anju Sharma, Dinesh Dhanwal
July-August 2014, 18(4):558-564
DOI:10.4103/2230-8210.137519  PMID:25143917
Background: To evaluate if hormonal profile of children with isolated hypospadias (IH) associates better with comprehensive local anatomical factor score (LAFS) than with clinically adjudged urethral meatus location or severity of chordee/k.j. Material and Methods: Ninety-nine children with IH were enrolled, as per inclusion criteria. Meatal location was recorded at first clinical examination in OPD; while LAFS was computed per-operatively using indigenously devised scale, except for neonates. Hypospadiacs were first classified into three standard meatal based groups and subsequently into LAFS based two groups (≤19, >19). For all participants, pre HCG and post HCG (96 hour post- injection) estimation of serum gonadotropins, DHEA-S, estrogen (E), progesterone (P), testosterone (T) and Dihydrotestosterone (DHT) was done. Statistical tests were applied to assess significance of hormonal levels with respect to meatal location, chordee and LAFS. Results: Only FSH levels differed significantly among meatal based groups; while among LAFS groups, multiple hormonal differences were noted; with poor LAFS associated significantly with higher FSH, LH and lower E, T/DHT. Children with severe degree of chordee had poorer T output and a significantly lower LAFS as compared to those with moderate/mild chordee. Conclusion: Serotoli cell dysfunction, indirectly indicated by high FSH was found among midpenile hypospadiacs and those with poorer LAFS. Since groups based on LAFS revealed multiple intergroup hormonal differences than what was seen for meatal/chordee based groups; LAFS should be considered a better guide for prognostication and for deciding about hormonal supplementation. Lower androgenic output was particularly noted in children with severe chordee.
  1,279 226 2
Low maternal iodine intake and early pregnancy hypothyroxinemia: Possible repercussions for children
Shan Elahi, Saeed Ahmad Nagra
July-August 2014, 18(4):526-530
DOI:10.4103/2230-8210.137513  PMID:25143911
Objective: Recent studies have shown that early pregnancy hypothyroxinemia (lower free thyroxin [FT 4 ] and normal thyroid stimulating hormone [TSH] concentration) has deleterious effects on neuro-intellectual development of children. This study was designed to know its incidence in local pregnant women. Materials and Methods: Urinary iodine (UI) and serum thyroid related hormone (FT 4 , free triiodothyronine [FT 3 ], and TSH) were determined in 254 pregnant women during the first trimester. UI and thyroid related hormones were determined by colorimetric (Sandell-Kolthoff) and radioimmunoassay method respectively. Results: Most of the pregnant women (n = 202; 79.5%) were iodine deficient (ID; UI <100 μg/L) and only 52 (20.5%) women were taking sufficient iodine (IS; UI ≥ 100 μg/L). Mean levels of FT 4 , FT 3 , and TSH were 13.0 ± 2.8 pmol/L, 3.8 ± 1.1 pmol/L and 1.2 ± 1.1 mIU/L, respectively. Maternal FT 4 levels were significantly correlated with UI (r = 0.36; P < 0.001). Mean FT 4 level in IS women was significantly (P < 0.05) higher than ID women. However, mean FT 3 and TSH levels were not significantly different in both groups. FT 4 reference range in IS pregnant women was 10.2-19.4 pmol/L. Hypothyroxinemia (FT 4 <10.2 pmol/L and TSH <2.5 mIU/L) was diagnosed in 30 (11.8%) pregnant women. Its incidence was almost entirely confined to ID pregnant women with an odd ratio of 8.5 (95% confidence interval: 1.1-64.3). Conclusion: About 12% pregnant women residing in urban areas of Pakistan are hypothyroxinemic because of low iodine intake.
  1,191 305 1
Comparison of Tc-99m pertechnetate images with dual-phase Tc 99m MIBI and SPECT images in primary hyperparathyroidism
Sait Sager, Hojjat Shafipour, Sertac Asa, Sabire Yilmaz, Serkan Teksoz, Cetin Onsel
July-August 2014, 18(4):531-536
DOI:10.4103/2230-8210.137520  PMID:25143912
Background: The purpose of this study was to evaluate the value of Tc-99m pertechnetate planar, dual-phase MIBI and MIBI-SPECT images in the determination and localization of parathyroid lesions. Materials and Methods: In this study, 38 patients who underwent operation for primary hyperparathyroidism were included. Tc-99m pertechnetate planar-pinhole imaging of the neck and then MIBI planar and SPECT images in supine position was performed. Late SPECT images were acquired 120 minutes after the injection. Early and late MIBI images were quantitatively evaluated. Results: Of the 38 patients, 30 of them had adenoma, 2 patients had hyperplasia and 6 of them were normal on planar images. Thirty-four of 38 patients were positive on SPECT images. SPECT images of the patients with positive results were matched with pathology results. Conclusion: As a result, Tc-99m pertechnetate planar-pinhole, Tc-99m MIBI planar and SPECT images are useful for localization of parathyroid lesions especially in multinodular thyroid gland. However, US or CT images are necessary for more accurate localization and Tc-99m pertechnetate images are useful for interpreting and comparing with the early and late MIBI images.
  1,128 291 -
RET mutations in a large indian family with medullary thyroid carcinoma
DM Mahesh, Arun G Nehru, MS Seshadri, Nihal Thomas, Aravindan Nair, Rekha Pai, Simon Rajaratnam
July-August 2014, 18(4):516-520
DOI:10.4103/2230-8210.137508  PMID:25143909
Background: Medullary thyroid carcinoma (MTC) is a tumor arising from the para follicular (C) cells of the thyroid gland and can occur either sporadically or as part of an inherited syndrome. A proportion of these cases carry an autosomal dominant mutation in the RET (REarranged during Transfection) proto-oncogene. Screening for these mutations in the affected patients and the carriers ''at risk'' which includes the first-degree relatives is of utmost importance for early detection and prompt treatment including prophylactic thyroidectomy in cases that harbor these mutations. Results: This report presents details of screening and subsequent follow-up of a large Indian family, where the index case was found to carry p.Cys634Ser mutation involving exon 11 of the RET gene. These data are of value considering the paucity of information within the region in context of screening large families affected by these mutations.
  1,129 250 1
Preliminary study: Evaluation of melatonin secretion in children and adolescents with type 1 diabetes mellitus
Yilmaz Kor, Iclal Geyikli, Mehmet Keskin, Muslum Akan
July-August 2014, 18(4):565-568
DOI:10.4103/2230-8210.137521  PMID:25143918
Objective: Melatonin is an indolamine hormone, synthesized from tryptophan in the pineal gland primarily. Melatonin exerts both antioxidative and immunoregulatory roles but little is known about melatonin secretion in patients with type 1 diabetes mellitus (T1DM). The aim of this study was to measure serum melatonin levels in patients with T1DM and investigates their relationship with type 1 diabetes mellitus. Materials and Methods: Forty children and adolescents with T1DM (18 boys and 22 girls) and 30 healthy control subjects (17 boys and 13 girls) participated in the study. All patients followed in Pediatric Endocrinology and Metabolism Unit of Gaziantep University Faculty of Medicine and also control subjects had no hypertension, obesity, hyperlipidemia, anemia, and infection. Blood samples were collected during routine analysis, after overnight fasting. Serum melatonin levels were analyzed with ELISA. Results: There were no statistically significant differences related with age, sex, BMI distribution between diabetic group and control group. Mean diabetic duration was 2.89 ± 2.69 years. The variables were in the equation. Mean melatonin level in diabetic group was 6.75 ± 3.52 pg/ml and mean melatonin level in control group was 11.51 ± 4.74 pg/ml. Melatonin levels were significantly lower in diabetic group compared to controls (P < 0.01). Conclusions: Melatonin was associated with type 1 diabetes mellitus significantly. Because of the varied roles of melatonin in human metabolic rhythms, these results suggest a role of melatonin in maintaining normal rhythmicity. Melatonin may play role in preventing process of inflammation and oxidative stress.
  1,003 294 6
EDITORIALS
Indian Journal of Endocrinology and Metabolism: Cover art
Sanjay Kalra
July-August 2014, 18(4):443-444
DOI:10.4103/2230-8210.137483  PMID:25143896
  1,031 209 -
ORIGINAL ARTICLES
A retrospective study of surgically excised phaeochromocytomas in Newfoundland, Canada
Joanna Holland, Vikram Chandurkar
July-August 2014, 18(4):542-545
DOI:10.4103/2230-8210.137514  PMID:25143914
Objective: A retrospective study detailing the circumstances surrounding diagnosis and treatment of pheochromocytomas with the associated genetic disorders. Materials and Methods: All patients with surgically excised pheochromocytomas in the Health Sciences Center, St. John's, Newfoundland, Canada between January 2001 and December 2010 were retrospectively analyzed to determine associated familial syndromes, age, tumor size, symptomatology, and percentage of paragangliomas and bilateral pheochromocytomas. Pathology specimen reports, adrenalectomy lists and Meditech (electronic medical record) diagnostic codes provided a comprehensive database for this study. Results: Twenty-four patients were studied; familial disorder patients comprised 42% (10/24). Average age at diagnosis was 57 among the sporadic and 34 in familial disorder groups (P = 0.006). Average tumor size was 4.5 cm in the sporadic group and 3 cm in the familial disorder group (P = 0.19). All atypical cases including bilateral or extra-adrenal tumors and malignancy occurred in familial disorder patients. Conclusions: The proportion of familial disorder patients (42%) was higher in this study than would be expected, likely a result of the relatively high incidence of hereditary autosomal dominant disorders within Newfoundland. Among familial disorder patients, the average younger age at diagnosis and the smaller tumor size suggest syndromic pheochromocytomas may develop earlier, however they are more likely to be diagnosed sooner due to biochemical surveillance testing in known genetic disorder patients. We also demonstrate a relatively high incidence of surgically resected pheochromocytomas of 4.679/million/year in Newfoundland.
  1,003 174 2
LETTERS TO THE EDITOR
Response to review article "Type 1 diabetes and osteoporosis: Review of literature"
Ameya S Joshi, Premlata K Varthakavi, Nikhil M Bhagwat, Manoj D Chadha
July-August 2014, 18(4):589-590
DOI:10.4103/2230-8210.137505  PMID:25143926
  805 258 -
Response to "Health economics in India: The case of diabetes mellitus"
Yashdeep Gupta, Rajiv Singla
July-August 2014, 18(4):588-589
DOI:10.4103/2230-8210.137503  PMID:25143925
  696 185 -
Comment on the editorial "Health Economics in India: The case of diabetes mellitus"
Koteshwara Muralidhara
July-August 2014, 18(4):587-587
DOI:10.4103/2230-8210.137502  PMID:25143924
  541 157 -
ERRATUM
Erratum

July-August 2014, 18(4):581-581
  446 109 -
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